Tag Archives: CBT

The New York Times reported on a terrific study at the University of Pittsburgh, looking at ultra short treatment of insomnia in the elderly. According to the article roughly 1/4 of older adults suffer from insomnia. The researchers streamlined an approach called CBT-I, which stands for cognitive behavioral therapy of insomnia.

There were only two sessions of treatment, totaling about 90 minutes. There were also two brief follow-up phone calls, over the first month. They tested this brief treatment and 79 seniors with chronic insomnia.

So what were the results of this study? They couldn’t have been very powerful, right?

Wrong. Two thirds of the CBT-I group reported a clear improvement in sleep, compared with only 25% of the people in the control group. Even better, 55% were cured of their insomnia. And six months later the results were even better.

So what was this magic treatment and the magic rules for curing insomnia? There were only four rules.

Spend only seven or eight hours in bed.

Set your alarm and get up at the same time everyday.

Never go to bed until you actually feel sleepy.

If you are tossing and turning and can’t sleep, get out of bed and do something relaxing until you get sleepy again. Then go back to bed.

These are standard cognitive behavioral sleep hygiene rules. And they are very powerful. Although not mentioned in the study, a few other rules are also helpful.

Regular exercise performed no later than midday is also helpful.

Reducing caffeine, nicotine, and alcohol all are helpful.

Avoid all naps.

Only use your bedroom for sleep and sex. Don’t watch TV or read in bed.

So why isn’t this treatment widely available? Could it be because there isn’t a powerful drug lobby for sleeping pills pushing this very effective therapy?

What is really tragic is that most seniors end up being prescribed sleeping pills for insomnia. And this is in spite of very clear data from research that shows that modern sleeping pills such as Ambien, Lunesta, or Sonata, have very minimal effects. On average they reduced the average time to fall asleep by 12.8 minutes compared to placebo, and increased the total sleeping time by only 11.4 minutes.

How can this be? Why is it that patients believe that sleeping pills are much more effective? The answer is very simple. All of these drugs produce a condition called anterograde amnesia. This means that you cannot form memories under the influence of these drugs. So you don’t remember tossing and turning. If you can’t remember tossing and turning even though you may have, then you perceive your sleep has been better. The drugs also tend to reduce anxiety, so people worry less about having insomnia, and thus feel better.

The hazards of sleeping pills in older adults include cognitive impairment, poor balance, and an increased risk of falling. One study in the Journal of the American geriatrics Society found that even after being awake for two hours in the morning, elder adults who took Ambien the night before failed a simple balance test at the rate of 57% compared to 0% in the group who took placebo. This is pretty serious impairment. Interestingly enough, in the same study, even young adults who took Ambien showed impaired balance in the morning.

So what are the key messages here?

1. Even though sleeping pills give people a sense of perceived improvement in sleep, the actual improvement tends to be almost insignificant, especially with the newer and very expensive sleeping medications. The older medications increased sleep time a little better, but have more issues with addiction and tolerance. Side effects of these medications are potentially very worrisome, since they can cause cognitive impairment and increased falling which leads to injuries, especially in the elderly. Why risk these side effects for such small improvements in sleep quality?

2. Cognitive behavioral therapy for insomnia works better than sleeping pills, has no side effects, is cheaper in the long run, and has a lasting impact on sleep improvement.

3. Most people who suffer insomnia will see their physician, who will prescribe sleeping pills. This is partly because of the lack of availability of cognitive behavioral treatment for insomnia. There are relatively few cognitive behavioral practitioners, and even fewer who regularly do CBT-I. We need to improve the availability of these treatments, and should follow in the footsteps of the University of Pittsburgh researchers in learning how to streamline these treatments. Most people don’t have the patience to spend 6 to 8 weeks in cognitive behavioral therapy for insomnia. Instead we need treatments that can be administered in a single week or two with some brief follow-up.

4. CBT-I availability will always suffer from the fact that there is no powerful corporate interest backing it. There are no CBT-I sales reps going to doctors offices offering free samples of CBT-I for doctors to pass out to their patients. I don’t have a solution for this problem, but would be interested in hearing from my readers as to how we might more effectively promote effective and safe treatments such as CBT-I.

Okay, now that I’ve written this, it’s time to trundle off to bed. As Hamlet said, “To sleep — perchance to dream. Ay, there’s the rub!”

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

Sometimes clients really integrate the learning about Cognitive Behavioral Therapy, and share it with family members. I was very moved when a client recently shared with me an email she wrote to her two teenage children. She gave me permission to publish it here, with a few identifying details deleted. Here it is:

To my dear children, please read this email because it will help you live life more peacefully.

I have lived my whole life worrying and I’m sick of it so I’ve spent the past months studying how to combat it. Here are some tips I’ve learned that should help you too.

As Dr. Gottlieb shared with me, here are key questions to ask yourself after making a mistake or facing something you think is devastating, in order to put the mistake into perspective

Did anyone die or get hurt? Remember, what doesn’t kill you makes you stronger.

Will I remember it in 1 or 5 years?

Did I lose a lot of money? (Defined as an amount that would truly change your way of life. ($100, $1000, or $10,000)

Is the mistake easily fixable with time or money or words?

What can I learn?

Does it really matter in the grand scheme of things?

OK, so the last point is the hardest. Of course it always seems to totally matter and be catastrophic. However, this brings me to the next step of Cognitive Behavior Therapy (CBT).

Sit with your thoughts. Then ask yourself what are your negative thoughts causing you to feel this way. For instance, “I’m going to get into a horrible college, have a lousy job, be poor, get fired, be miserable, etc.”

THEN recognize these thoughts. Are they all-or-nothing thinking? Am I mind reading, assuming that others feel this way? Am I being catastrophic, blowing this out of proportion?

Once you determine that this is really a distorted thought, then examine the thought in a healthier way. You can step back and ask yourself on a scale of 0-100, how bad is this current event really? Think of something tragic that would be a 100 (ie: parent dying, you getting cancer, etc.). Ugh. Then compare the current event with the true 100 catastrophic event.

To help you determine the true number, ask yourself a series of “what if” statements for healthier thinking. For instance: “What if I don’t get an A…. I won’t get into a good college… if this is true then what if you don’t get into a good college…. I won’t get a good job…. if this is true what if you don’t get a good job…. I’ll be unemployed forever, be poor and miserable”…. Is this really true? No. You can think of people who didn’t attend college and are successful. You can even think of the opposite of people who DID attend a prestigious school and never worked outside of the home. You can think that there are ALL types of jobs that require all types of skills.

Then re-number your worry. It’s probably much lower. If not, review Dr. Gottlieb’s key points above and go through this exercise again. Most of the time the worry/event isn’t as bad as we think.

Finally, turn unproductive worry into product worry. Unproductive worry is just thinking OMG, OMG, OMG! That doesn’t help. However, productive worry is problem solving. You switch the energy into something productive and try to solve the problem.

And one last thing, remember that if you’re mind reading (believing that others will think negatively of you), no one really cares. True, your parents and close ones do care about the important stuff, but truly no one looks at you. Everyone is a self-centered, too busy focused on them to be concerned about you. And if you assume that people are thinking something negatively about you, do the above steps, asking yourself to replace this with a more realistic/healthier thought and the what if exercise. Remember, just because you may have judgmental thoughts, doesn’t mean everyone else is. The first step is to stop judging others and be more compassionate. Once you stop being so judgmental of others, you’ll start treating yourself nicer and have better self esteem.

I hope that you read and implement these tips so you can lead happier, more peaceful lives. And just think, I’ve saved you hours and hours of reading, studying and discussing this stuff… You get the Spark Notes version.

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

“Jack and Jill went up the hill
To fetch a pail of water.
Jack fell down and broke his crown
And Jill came tumbling after.
Jack blamed Jill,
Jill blamed Jack,
And each vowed they would
Never come back.”

What is the secret of good couples communication? What one simple skill tremendously improves the ability of couples to discuss difficult subjects?

It is the skill of non-defensive responding. What do I mean by this?

Let me give you an example. Imagine a hypothetical couple Jack and Jill. Jack comes home from work and is tired and hungry. Jill got home from her job one hour before. She’s sitting on the couch reading the paper.

A typical response that Jill might make would be something like, “You’ve got hands, why don’t you make dinner! Why do you expect me to be your slave!?”

At which point it is likely a good fight would ensue.

The non-defensive response would be something like, “It sounds like you’re really hungry and kind of annoyed that I haven’t started dinner yet. You’re absolutely right, I was really stressed out when I got home from work and I decided to relax for a while rather than start dinner. I can see how you would feel frustrated getting home from work tired and hungry and seeing me just sitting here. Why don’t you sit down and relax and I’ll get us some quick snacks, and then get dinner started.”

Notice the difference. In the first example Jill counterattacks. Jack will counterattack in return and quickly things will escalate into a full fight.

In the non-defensive example Jill acknowledges Jack’s feelings. Then she finds some truth in his statement. Next she validates his feelings. And finally, she proposes a solution.

This is an incredibly powerful skill for reducing conflict and improving communication between people. In this article I will give you some basic theoretical rationale for why non-defensive responding works so well, and then teach you — step-by-step — how respond non-defensively.

First the theory. Human ego is a delicate thing. We spend a lot of our energy defending our sense of self against attacks or criticisms. The problem with this model is that it’s impossible to defend completely against all attacks or criticisms. This is because most of us are very far from perfect — we are quite flawed — and we know it.

The problem is that we don’t accept it. We have this all or nothing model of ourselves which says either we are perfect or we are awful. So when any criticism comes along, it challenges our model of being perfect and we slip into the painful feelings of complete inadequacy.

We don’t like feeling inadequate, so we try to deny or counterattack any criticism. There are so many types of defensive responding that it’s difficult to catalog all of them. But some of the major types of defensive responding are described below. (These are based on John Gottman’s work on communication.)

Major Kinds of Defensiveness

1. Denying responsibility. This involves denying that you’re at fault no matter what your partner accuses you of. If your wife says you hurt her feelings by saying something insensitive, you reply that you didn’t do anything wrong.

2. Making excuses. This is when you acknowledge the mistake, but create a reason for why circumstances outside your control forced you to make the mistake. Classic examples of this are, “traffic made me late,” or “I just forgot to pick up the milk.”

3. Disagreeing with negative mind reading. This is when you disagree with your partner’s interpretation of your internal state or emotion.

Jack: You seemed very frustrated with me tonight.
Jill: That’s not true, I was just tense being at a work party.

Jill: you never take me out anymore.
Jack: and you never cook me dinner anymore!

5. Rubber man/rubber woman. This is based on the old saying, “I’m rubber, you’re glue. Whatever you say bounces off me and sticks to you.” In this form of defensiveness, you immediately counterattack with a similar criticism.

Jack: You were very mean to me at the party tonight.
Jill: Well you were mean to me yesterday when we visited your mother’s house.

6. Yes-Butting. This is where you start off agreeing, but then end up negating the agreement.

Jack: You said you would put away your work papers off the dining room table.
Jill: Yes I did, but I was waiting for you to clear off your books first.

7. Repeating yourself. This involves repeating the criticism again and again without listening to your partner.

8. Whining. This involves the sound of your voice and the stressing of one syllable at the end of this sentence. For instance, “You always ignore me at parties.”

9. Body language. Typical body language signs of defensiveness are crossing your arms across her chest, shifting side to side, and a false smile.

Ultimately the goal of all defensiveness is to preserve the self. This is a commendable but hopeless goal, since defensiveness triggers elevated levels of criticism from the other person. As Gottman has so elegantly described, the more you defend yourself, the harsher the criticism you receive. That’s because when someone criticizes you they want you to acknowledge the validity of their feelings and thoughts. When you respond defensively you are invalidating them, so they escalate the criticism. If you can’t hear them the first time, they say it louder.

This of course leads you to become even more defensive because the criticism is now much harsher. And the two of you are off to the races! The fight escalates, gets personal, and both of you end up feeling damaged.

So what is the solution? How do we get out of this vicious cycle of defensiveness and criticism?

The answer is a radical shift in the way we think about ourselves. Radical non-defensiveness is the answer.

What is radical non-defensiveness? First it requires a shift in our core beliefs about ourselves. Remember that most of us have an all-or-nothing model of our self. We believe, “I must be perfect otherwise I am crap. If anyone points out my imperfections, they are basically saying that I am crap, and I won’t listen and I will counterattack.”

Radical non-defensiveness means that we shift our core belief about ourself to, “I am a flawed human being. I make many mistakes. I can improve on almost anything I do. But even with my flaws I am a worthwhile and valuable person.”

With this radically changed belief about the self, criticism changes as well. Instead of criticism meaning that we are worthless human being, it simply acknowledges the reality of being flawed, and helps us to improve.

If you think about it for a moment, you might realize that radical non-defensiveness is the antidote to perfectionism. Perfectionism beliefs cause much human suffering. When we feel that we need to be perfect in order to be worthwhile we are living in a glass house. The smallest pebble can crack our armor. And that pebble can be any criticism.

The radical non-defensive model is completely the opposite of perfectionism. I don’t need to be perfect to be good and worthwhile. I can shoot for an 85 rather than 100. If I make a mistake, I can acknowledge it and realize that everybody makes mistakes.

Let’s go over — step-by-step — how to respond non-defensively. (Some of this is based on some of David Burns’s work on communication.)

First let’s create another example of criticism. Back to Jack and Jill. They have finished dinner, and Jack retires to his laptop computer, where he spends the next several hours deep in Internet surfing. Jill tries to talk to him about something that happened at work, but he ignores her. Finally, she explodes, “You never listen to me! You are always surfing on your stupid computer! You don’t care about me, and you’d rather watch YouTube videos than listen to my problems. You are an uncaring husband!”

Step One: Paraphrase back to the person the thoughts and feelings they are expressing to you.

Jack says, “It sounds like you’re really frustrated and angry with me right now, because I was on the computer rather than focusing on you.”

Step Two: Find SOME truth in what they are saying. In this step what you try to do is select whatever reality-based truth there is, and ignore hostile names or labels. You focus on the behavior that you’ve committed rather than the nasty labels.

Jack says, “You are absolutely right. I have been spending way too much time on my computer and not enough time connecting with you.”

Step Three: Validate the emotion paraphrased in Step One, and connect it to the behavior in Step Two. This lets the person know that many people, including you, might feel the same emotion in the same situation.

Jack says, “I can see why you might feel frustrated. If I wanted to talk more with you and you were reading all the time I’d probably feel the same way. It makes perfect sense.”

Step Four: Offer possible solutions. Here there are several options. One option is a genuine apology. This is very powerful. Another option is to suggest discussing the problem in order to find solutions. This option is best when the criticism encompasses a complex problem that can’t easily be resolved. Another option is to simply fix the problem right then and there.

Jack closes his computer and says, “I’m really sorry. I do want to hear what happened at work, why don’t we sit together on the couch and talk about it.”

Step Five: Thank the other person for bringing the problem to your attention. This is probably the most alien step of all for most people. How can you thank someone for criticizing you? If you recall in the radical non-defensiveness model, you acknowledge that you can always improve, and that criticism is often what helps you to improve. So thanking the person for criticizing you is really saying thank you for caring enough about me to help me improve.

Jack says, “Thanks Jill for telling me how you feel. That allows me to be more conscious of being a better husband. Thanks again.”

One typical objection to non-defensive responding is “Won’t the the other person criticize me more if I don’t defend myself?” The truth is actually the opposite. The more you defend yourself the more criticism you receive, and the harsher the criticism becomes. Most criticism is designed to create change or to be listened to, and defensive responding achieves neither.

Another objection is, “What if the criticism is completely unfounded or unjust? How can I respond non-defensively in that case?”

Criticism is rarely completely unfounded. There is almost always SOME truth in most criticism. Even if it just factual truth, you can agree with it. Example:
Jill: You were flirting with that woman Nancy at the party. You’d like to sleep with her.
Jack: You are absolutely right, I was flirting a little. I can see how that would upset you. I don’t want to sleep with her though. What can we do at the next party so I don’t upset you?

Try using this skill at home, at work, with friends, and with family. You will be surprised at how effective it is. I’ve summarized the steps below.

Now I’ve got to go apologize to my sweetie for spending so much time writing this….

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.

A very interesting study recently published in the Journal of the American Medical Association (JAMA) demonstrated very clearly that when it comes to antidepressant medication, the Emperor is wearing few if any clothes! The researchers did what is called a meta-study or meta-analysis. They searched the research literature for all studies that were placebo-controlled studies of antidepressants when used for depression. That means the studies had to include random assignment to either a medication group or a placebo (sugar pill) group. They eliminated some studies which use a placebo washout condition. (This means the studies first gave patients a placebo, and then eliminated all patients who had a 20% or greater improvement while taking placebo.) When they eliminated all studies that didn’t meet their criteria, they were left with 6 studies of 738 people.

Based on scores on the Hamilton Depression Rating Scale (HDRS), the researchers divided the patients into mild to moderately depressed, severely depressed, and very severely depressed. This is a 17 item scale that is filled out by a psychologist or psychiatrist, and measures various aspects of depression. It is used in most studies of depression. They then analyzed the response to antidepressant medication based on how severe the initial depression was.

The two antidepressants studied were imipramine and paroxetine (Paxil). Imipramine is an older, tricyclic antidepressant, and Paxil is a more modern SSRI antidepressant.

What did they find? They were looking at the size of the difference between the medication groups and the placebo groups. Rather than do the typical thing of just looking at statistical significance, which is simply a measure of whether the difference could be explained by chance, they looked at clinical significance. They used the definition used by NICE (National Institute of Clinical Excellence in England), which was an effect size of 0.50 or a difference of 3 points on the HDRS. This is defined as a medium effect size.

What they found was very disheartening to those who use antidepressant medications in their practices. They divided the patients into three groups based on their initial HDRS scores: mild to moderate depression (HDRS 18 or less), severe depression (HDRS 19 to 22), and very severe depression (HDRS 23 or greater).

For the mild to moderately depressed patients, the effect size was d=0.11, and for severely depressed patients the effect size was d = 0.17. Both of these effect sizes are below the standard description of a small effect which is 0.20. For the patients in the very severe group, the effect size was 0.47 which is just below the accepted value of 0.50 for a medium effect size.

When they did further statistical analysis, they found that in order to meet the NICE criteria of effect size of a 3 points difference, patients had to have an initial HDRS score of 25 or above. To meet the criteria of an effect size of .50, or medium effect size, they had to have a score of 25 or above, and to have a large effect size, 27 or above.

What does this all mean for patient care? It means that for the vast majority of clinically depressed patients who fall below the very severely depressed range, antidepressant medications most likely won’t help. The sadder news is that even for the very severely depressed, medications have a very modest effect. Looking at the scoring of the HDRS, the normal, undepressed range is 0 to 7. The very severely depressed patients had scores of 25 or above, and a medium effect size was a drop in scores of 3 or more points compared to placebo patients. Looking at the one graph in the paper that show the actual drops in HDRS scores, the medication group had a mean drop of 12 points when their initial score was 25. That means they went from 25 to 13, which is still in the depressed range, although only mildly depressed. Patients who initially were at 38 dropped by roughly 20 points, ending at 18, which is still pretty depressed. And the placebo group had only slightly worse results.

One interesting thing is how strong the placebo effects are in these studies. It seems that for depressions less serious than very severe, placebo pills work as well as antidepressant medication. Is this because antidepressants don’t work very well, or because placebos work too well? It’s hard to know. Maybe doctors should give their patients sugar pills, and call the new drug Eliftimood!

So in summary, here are the main observations I make from this study.

If you are very severely depressed, antidepressants may help, and are worth trying.

If you are mildly, moderately, or even severely depressed, there is little evidence that antidepressants will help better than a placebo. You would be better off with CBT (Cognitive Behavioral Therapy), which has a proven track record with less severe depressions, and which has no side effects.

Interestingly, CBT is less effective for the most severe depressions, so for these kinds of depressions medication treatment makes a lot of sense.

If you are taking antidepressants and having good results, don’t change what you are doing. You may be wired in such a way that you are a good responder to antidepressants.

If you have been taking antidepressants for mild to severe (but not very severe) depression, and not getting very good results, this is consistent with the research, and you might want to discuss alternative treatments such as CBT with your doctor. Don’t just stop the medications, as this can produce withdrawal symptoms, work with your doctor to taper off them.

Even in very severely depressed patients, for whom antidepressants have some effects, they may only get the patient to a state of moderate depression, but not to “cure”. To get to an undepressed, normal state, behavioral therapy may be necessary in addition to medications.

How do you find out how depressed you are? Unfortunately there is no online version of the HDRS for direct comparison. You may want to see a professional psychologist or psychiatrist if you think you might be depressed, and ask them to administer the HDRS to you. There are also online depression tests, such as here and here. If you score in the highest ranges you might want to consider trying antidepressant medications, if you score lower you might want to first try CBT.

The most important thing is not to ignore depression, as it tends to get worse over time. Get some help, talk to a professional.

I’m off to take my Obecalp pills now, as it’s been raining here in Northern California for more than a week, and I need a boost in my mood. (Hint: what does Obecalp spell backwards?)

Dr. Andrew Gottlieb is a clinical psychologist in Palo Alto, California. His practice serves the greater Silicon Valley area, including the towns of San Jose, Cupertino, Santa Clara, Sunnyvale, Mountain View, Los Altos, Menlo Park, San Carlos, Redwood City, Belmont, and San Mateo. Dr. Gottlieb specializes in treating anxiety, depression, relationship problems, OCD, and other difficulties using evidence-based Cognitive Behavioral Therapy (CBT). CBT is a modern no-drug therapy approach that is targeted, skill-based, and proven effective by many research studies. Visit his website at CambridgeTherapy.com or watch Dr. Gottlieb on YouTube. He can be reached by phone at (650) 324-2666 and email at: Dr. Gottlieb Email.